SRS

Medical Certificate

SAMPLE

To the physician of Yanhee Hospital whom it may concern,

This is to certify that I diagnose Mr. SAMPLE NAME

as having GID Gender Identity
Disorder .

Name: SAMPLE NAME
Sex given at birth: SAMPLE
Sex self-identified : SAMPLE
Date of birth: SAMPLE years old
Diagnosis: SAMPLE Disorder
Date of Diagnosis: SAMPLE
Date:
Signature:

SAMPLE

SAMPLE

SAMPLE NAME , MD, PhD

Chief physician,
SAMPLE CLINIC NAME
Disclaimer:
1. This diagnosis is based sololy on oral concultation and his life history statement in his own writing.
2. Japanese regulation including the guidline concerning GID diagnosis and evaluating the appropriateness for
SRS requires additional examination and one more diagnosis by third party physician in addition to this
diagnosis and certificate.
3. No one may not perform SRS surgery based upon this diagnosis and certificate in Japan geograficaly nor in
Japanese jurisdiction legally.

SRS